**2.2. Program governance**

Pakistan went through devolution of its services related public sectors including health sector with the 18th amendment in its constitution effective from June 28, 2011. The Federal Ministry of Health (MoH) was dissolved and the overall responsibility for health services policy direction and planning was devolved to the provinces [14]. Inefficiencies and stalled health system's performance was observed at nearly all of the operational levels for some time after the devolution of 2011 [15]. A lack of clarity in roles and responsibilities of federal and provincial tiers of the government resulted in a vacuum in governance, and weak stewardship at decision-making levels The National Health Vision 2016–2025 later outlined more clearly the roles and responsibilities of the federal and provincial government vis-à-vis health programs and interventions [16]. There is a proposal that going forward, each district must have its own EPI implementation plan, which should consider and address the gaps identified by the situational assessment [13]. Polio in Pakistan has generated much analysis and discussion at the global and national levels. In late 2014, due to a rise in polio cases, an Emergency Operations Centre was established, and was mandated to ensure a synergy between the Polio Eradication Initiative and EPI, as well as with other sectors. Nevertheless, this convergence or synergy is still to be seen as fully operational [17]. The role of the private sector as a key stakeholder has also been documented with regard to governance of EPI [18], which could work hand in hand with the public sector in order to achieve the desired targets of immunization; but its potential still remains untapped.

#### **2.3. Human resource**

**2. Factors influencing EPI implementation**

70 Immunization - Vaccine Adjuvant Delivery System and Strategies

**2.1. Program financing**

**2.2. Program governance**

responsible for the current state of affairs of EPI in Pakistan.

The information gleaned from the peer-reviewed articles, government reports, EPI documents, WHO/UNICEF/GAVI reports and some gray literature, unravels a stagnant or declining immunization status. At the same time, this analysis also shows a multifactorial picture

Development partners have always generously supported the maternal, child and newborn health programs in Pakistan [12]. Although the immunization program mainly depends upon domestic development funds, resources from donors (WHO, UNICEF, GAVI, etc.) have been instrumental too. Pakistan is the biggest recipient of GAVI at present, categorized as a Tier 1 priority country. GAVI financial support to the Pakistan government has been channeled through partner organizations, predominately, WHO and UNICEF [13]. The Government of Pakistan's own share represents approximately 20% of the total EPI allocations [6]. The Japan International Cooperation Agency (JICA) and the World Bank also support the program. Moreover, the donors have supported in-service trainings for EPI managers. However, delayed release of funds and inefficiencies in expenditure have been noted as some key issues in the past. Of particular note is the lack of appropriation for transportation and fuel costs. Shortage of funds for repair and maintenance of cold chain equipment and vehicles could jeopardize vaccine efficacy [13].

Pakistan went through devolution of its services related public sectors including health sector with the 18th amendment in its constitution effective from June 28, 2011. The Federal Ministry of Health (MoH) was dissolved and the overall responsibility for health services policy direction and planning was devolved to the provinces [14]. Inefficiencies and stalled health system's performance was observed at nearly all of the operational levels for some time after the devolution of 2011 [15]. A lack of clarity in roles and responsibilities of federal and provincial tiers of the government resulted in a vacuum in governance, and weak stewardship at decision-making levels The National Health Vision 2016–2025 later outlined more clearly the roles and responsibilities of the federal and provincial government vis-à-vis health programs and interventions [16]. There is a proposal that going forward, each district must have its own EPI implementation plan, which should consider and address the gaps identified by the situational assessment [13]. Polio in Pakistan has generated much analysis and discussion at the global and national levels. In late 2014, due to a rise in polio cases, an Emergency Operations Centre was established, and was mandated to ensure a synergy between the Polio Eradication Initiative and EPI, as well as with other sectors. Nevertheless, this convergence or synergy is still to be seen as fully operational [17]. The role of the private sector as a key stakeholder has also been documented with regard to governance of EPI [18], which could work hand in hand with the public sector in order to achieve the desired targets of immunization; but its potential still remains untapped.

The lack of a comprehensive human resource (HR) strategy has been discussed time and again in the context of EPI in Pakistan. There is no regular and formal training program for the management cadres, and learning is mostly self-directed and on the job. Managers often lack the practical knowledge for leading program operations proficiently [19]. EPI workers' fatigue due to frequent polio campaigns have reduced their time dedicated to routine EPI vaccination initiatives [13]. In-service training for routine immunization staff is not held on the basis of any planning and programming, rather it is conducted whenever the donor funding is available. Competency of the staff, outreach capacity, service structure, attitudes toward clients, political interference in transfers and postings, and lack of accountability are all notable HR related issues of EPI [20, 21]. On the other hand, there are workers in the Polio program who are willing to perform their duties while putting their lives at risk, and facing extremist sections of the society, amidst a grim law and order situation [22]. Introducing incentive structures among managers and health workers of EPI or contracting with non-governmental organizations (NGOs) can potentially improve the HR performance [23].
